Preventing Neuropathy during Chemotherapy
Nerve Damage Can Be Long-Lasting After Chemo for Early-Stage Breast Cancer
Older and heavier women may be especially at risk, and options for neuropathy treatment are few, a study says.
By Don Rauf
Medically Reviewed by Thomas Marron, MD, PhD
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A chemotherapy drug commonly used to treat early-stage breast cancer may leave patients with unpleasant side effects, and should be monitored carefully, according to a study published in August 2019 in theJournal of the National Cancer Institute.
The drug, Taxotere (docetaxel), is part of a class of drugs known as taxanes, which also include Taxol (paclitaxel).
While these medications have been known to increase the risk of neuropathy (damage to the nerves), the new research has found that these symptoms may last for years.
Scientists reviewed data on 1,512 people with early-stage breast cancer who received adjuvant chemotherapy. This type of treatment is used to prevent recurrence after primary treatments such as surgery or radiation. The study found that more than 40 percent reported numbness and tingling in their hands and feet after two years of a regimen involving docetaxel.
One out of 10 patients characterized their neuropathy symptoms as severe. "For those who rated the severity as 'very much,' the quality of life score was almost 20 points lower compared with those with no bother," says the study’s senior author, Patricia Ganz, MD, the director of cancer prevention and control research at the Jonsson Comprehensive Cancer Center at the University of California in Los Angeles.
"We are hoping that oncologists will take note of the risk for long-term neuropathy, especially in older and heavier women," says Dr. Ganz. "Older and heavier women are more likely to have a risk for diabetes, which can also cause neuropathy," says Ganz.
Participants in the recent study received one of three therapies with Taxotere — Taxotere with Adriamycin (doxorubicin) at the same time; Taxotere with Adriamycin and Cytoxan (cyclophosphamide) at the same time (ACT), or Adriamycin and Cytoxan taken at the same time followed by the Taxotere (AC→T).
Those in the last group received the highest doses of the taxane. The first group, who took just Adriamycin and Taxotere, had slightly worse results in terms of survival compared with the other two. The ACT group, taking the three treatments at once, had a survival rate almost equal to those in the last group, who took the follow-up Taxotere, but it also had significantly less neuropathy.
"We hope that oncologists might consider the alternative treatment with ACT if there is concern for persistent neuropathy," says Ganz.
Ganz suggests that oncologists weigh the risk of persistent neuropathy against the treatment choice to give a taxane-based drug or not, as well as the dose to be given. Other taxanes, such as Taxol (paclitaxel), which is often given weekly instead of every three weeks, may be a better alternative for some patients.
Alternatives to a taxane include taking just AC (Adriamycin and Cytoxan) or FEC. FEC is Adrucil (5-fluorouracil or 5-FU), Ellence (epirubicin), and Cytoxan. "These are the regimens that were commonly used before the taxanes were introduced," says Ganz.
Patients Need to Be Better Informed
Ganz said that breast cancer patients may not anticipate having these kinds of side effects from chemotherapy.
"Our current research shows that oncologists spend a lot of time informing patients about the acute effects of chemotherapy (nausea, vomiting, fatigue, hair loss, mouth sores, low blood counts) and very serious or rare late effects such as leukemia or heart injury," says Ganz. "However, they rarely discuss the persistent or lingering effects of the chemotherapy treatment and how long they last and whether they are likely to go away."
Falls, disability, and cognitive difficulties may also increase among these patients because of the toxicity to their nerves.
Charles Loprinzi, MD, a professor of oncology at the Mayo Clinic in Rochester, Minnesota, agrees that chemotherapy-induced peripheral neuropathy is a major long-term problem for a substantial population of patients.
Dr. Loprinzi says that guidelines from the American Society of Clinical Oncology may have to be updated to reflect these study results. "The guidelines may need more information about how you educate patients about the degree of the problem," he says. "Some patients do not want to stop early; they want to tough it out, and they say it's not that bad and they can put up with it. I suspect that they don't really understand how bad it can be for a long time."
What Can Be Done When Neuropathy Symptoms Appear
Loprinzi says that when his patients get significant neuropathy or get it at a faster rate than expected, he often stops any taxane-based treatment.
Although there is no highly effective treatment for this nerve damage, there are multiple medications that can offer some relief. Loprinzi says that duloxetine is "the best drug we have at this time to treat established neuropathy." He notes, however, that it doesn't resolve the problem completely and has some side effects itself.
There are some pilot studies indicating that cryotherapy (using ice or other very cold substances) may also be helpful, according to Loprinzi. Further research results should be available in 2019.
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